Corrective Facials & Express Glow Facial Intake Form

Name *

First NameLast Name

Phone Number*

Area CodePhone Number

Email

example@example.com

Have you had a facial before?*

YESNO

What are your specific skincare concerns?

Any other reasons for a facial besides your concerns?

RelaxationSkincare EducationHelp with What is Best for My Skin

Give us an idea of what you typically use on your skin daily?*

Any known allergies?*

Have you ever been diagnosed with eczema, psoriasis or rosacea on the face?

YESNO

Are you currently using any products that contain:

Do you currently have any rashes, itching or underlying redness on your face?

Please list medications or supplements you are currently taking.

Have you ever received chemical peels, laser services, or microdermabrasion treatments?

YES, within the last monthYES, within the last 2-3 monthsNO

Have you had botox in the past 7 days?

YesNo

Have you had fillers in the past 14 days?

YesNo

Have you experiences any of these health conditions in the past or present?

Are you taking birth control?

YESNO

Are you pregnant?

YESNO

Are you Breast-Feeding?

YESNO

Acknowledgement and Waiver

I hereby agree to have this treatment be performed on me. I am aware that products used in facials and homecare can contain tree nuts, dairy and gluten, aspirin. I acknowledge that Bella Day Spa may use products that contain these ingredients or are manufactured in a plant with these ingredients. I am aware that even with natural ingredients there is a remote chance of an allergic reaction and there is a possibility of an adverse reaction to product used in facials.

I am also aware that certain services should not be performed with certain medical conditions. I have disclosed all my known medical conditions, allergies, medications and answered all questions honestly on the above form and agree to update Bella Day Spa as to any changes.

I CERTIFY that I am not on any retinal, Retin-A or actives that have been explained to me could cause minor complications during the peel process, burning sensation, peeling.

I acknowledge that the estheticians and staff at Skin Theory do not provide medical advice and I accept full responsibility to seek out such advice before receiving any services or products from Bella Day Spa. I hereby release, discharge and waive any and all claims against Bella Day Spa and each of their partners, employees, representatives or any person(s) performing services or applying any products at Bella Day Spa, including from liability and responsibility for any and all illness, injuries, damages, claims, rights and causes of action of any kind or nature, that may occur during or arising out of any services or products received on this and any future dates. I expressly assume and accept the risk for any injuries sustained. I have read this entire document and agree to its terms.

I voluntarily request that Bella Day Spa LLC perform the BioRepeelC13 Blue TCA
chemical peel procedure. I acknowledge having been informed that this cosmetic procedure is intended to remove surface layers of the skin to improve the vitality of the skin

Peels, despite their high levels of efficacy and safety, are not free of side effects. Erythema (redness) and edema (swelling) of the treated area can occur but usually subsides within a few hours but can last up to seven days or longer. Irritation, itching, and/or mild burning sensation or pain similar to sunburn may occur within 48 hours of treatment.

It is important to use sunscreen of SPF 50 or greater when exposed to the sun.

I understand complications can include white heads, cold sores, infection, scarring, numbness and possible permanent discoloration.

No guarantee, warranty, or assurance has been made to me as to the results that may be obtained. I am aware that follow-up treatments may be necessary for desire results. Most clients require a few treatments over time with gradual results occurring over time. Results will very per client. I agree to adhere to all safety precautions and regulations during the treatment. No refunds will be given for treatments received.

CONTRAINDICATIONS:

*BioRePeel should not be utilized with the following conditions listed below*
-Retinoids, AHA, BHA, Retinols, Antibiotics
**should be avoided 7-14 days prior and post care**
-Active bacterial infection, viral, fungal or herpetic infections
-Open wounds
-Pre-existing inflammatory dermatosis (i.e., psoriasis, atopic dermatitis, pemphigus)
-Skin cancer - MUST be cancer free for a period of 3 years and have direct written consent from a physician.
-Pregnant and breastfeeding
-History of drugs with photosensitizing potential
-Use of Accutane within a 6-8-month period
-Not fully recovered from any kind of cosmetic surgery
-Aspirin allergy

FOR SERVICES INVOLVING MINORS:

As the parent or legal guardian of {name} (minor’s name), I give permission for her/him to have a FACIAL SERVICE performed at Bella Day Spa.

By submitting this form electronically, I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended as a result of the treatment.

Signature

Facial / Chemical Peel / BioRePeel Blue Intake Form

Your Skin

Your Medical History

Females Clients